Open Enrollment 101- A GWG's Guide to the ACA Marketplace

It’s November, and you know what that means!

Sweaters, boots, turkey… and time to sign up for health insurance! As part of the Affordable Care Act (ACA), the insurance marketplace, also called the exchanges, at HealthCare.gov was first set up in 2014. You are likely more familiar with the nickname “Obamacare”. (Thanks, Obama!)

During most of the year, you can only enroll through HealthCare.gov if you have a “qualifying life event”- this includes situations like losing a job or having a baby. Open Enrollment is the period of time during which you can sign up for any reason. This year, the Open Enrollment period is only 45 days: November 1 - December 15. The current political climate has added a lot of changes and uncertainty to the market, so even if you’re already enrolled in an ACA plan for 2017, it’s important to shop around for 2018.

Speaking of all that political uncertainty- what does all that stuff I’ve heard in the news mean?

Despite the near constant efforts of the Trump administration and Congress to “repeal” the ACA, it is still the law. The cost of insurance plans for 2018 have already been set and will not be changed mid-year. Additionally, none of the proposed bills would have enacted significant changes until 2019. The individual mandate is still in place, so choosing not to have health insurance for 2018 can result in a fine of $695 or more.

The bottom line is that you can, and should, still sign up.

What population are ACA marketplace plans designed to help cover?

If you don’t qualify for Medicaid/Medicare and have a job that doesn’t offer health coverage, or you’re self-employed, or you own a small business, health insurance through HealthCare.gov may be a great option for you! These plans are usually most affordable for those whose yearly household income is between 100% and 400% of the federal poverty level (FPL). To give you an idea of the numbers, the 2017 FPL is $12,060 for an individual and $24,600 for a family of four. You can find a list of FPL based on household size here: https://www.healthcare.gov/glossary/federal-poverty-level-FPL/

I’ve heard that rates are going way up- will I be able to afford coverage?

There are two types of subsidies in place to assist people in paying for their health insurance premiums. The amount of support you qualify for is dependent on your income, your age, where you live, and the number of people in your household. Approximately 8 out of 10 who purchase insurance through HealthCare.gov receive some level of subsidy.

Advanced Premium Tax Credits (APTCs) are available to those whose yearly household income is 100-400% of FPL. APTCs are subsidies that help make your premium more affordable. Most people choose to have these funds paid directly to the insurance company, who will then lower your monthly bill by the corresponding amount. Alternatively, you can take your tax credit as a deduction on your 2018 taxes. This may be a good option if you think your income may change over the course of 2018.

Cost Sharing Reductions (CSRs) are for those whose yearly household income is 100-250% of FPL and require insurers to lower your out of pocket and deductible expenses. They are then reimbursed by the government for doing so. In October, President Trump ordered the Department of Health and Human Services Services to immediately stop CSR payments to health insurance companies. It may sound completely insane, but insurance companies are still required by law to provide you with these discounts going forward despite the government’s refusal to hold up their end of the deal.

To compensate for the loss of CSR reimbursements, most insurance companies have built these amounts into their rates for 2018. This factor, coupled with the high rate of medical inflation and the surge of political uncertainty around the ACA, accounts for most of the increase in premiums this year. However, if you’re eligible for APTCs and/or CSRs, your actual premiums and deductibles will likely stay about about the same- the actual value of the subsidies you receive are proportional to the cost of the plans.

Note: If if you make more than 400% of FPL, you are not eligible for ACA marketplace subsidies. Additionally, if you are eligible for employee-sponsored health insurance (either on your own or through a spouse/parent), you cannot receive any financial assistance towards an ACA plan. You may still be able to buy a reasonably priced plan directly from an insurer and not through HealthCare.gov (off-exchange plans). A list of these plans is available at https://finder.healthcare.gov/.

How do I know what plan is right for me?

ACA marketplace plans are classified by “metal level.” Plans with the highest premiums and lowest out of pocket costs are “platinum” plans, while “bronze” level plans are the opposite- you pay less up front each month, but these plans have higher deductibles and co-pays. If you usually hit your deductible quickly and pay the out of pocket max every year, a higher metal level plan is probably the best option. Although you pay more up front each month, you end up paying less overall for your medical expenses across the year. This applies to those of us on biologics (Remicade, Humira, Cimzia, Entyvio, etc.) or other drugs coming from a specialty pharmacy. A year's worth of ostomy supplies would likely put you squarely in this category, as well.

You should also check whether your doctors are in-network and whether your prescription drugs are covered before picking a plan- once Open Enrollment is over, you generally can’t change plans until the next Open Enrollment Period.

Well, this is all incredibly overwhelming. How do I start?

If you’d like to talk through your options, free in-person help is available from a trained professional at 1-800-318-2596 or http://localhelp.healthcare.gov.

Additionally, here are some good resources where you can read up on this to your heart’s content:

So there it is, ladies! If you have any questions, please feel free to post them in the comments section below and I will do my best to get you some answers! If you’d rather not publicly post, you can send me an email at blog@girlswithguts.org.

May your fall be full of the scarves, boots, and sweater dresses of your dreams!

I need to thank my husband Wesley, my personal and professional health policy wonk, for his input.